Strategies to improve nutrition in elderly people

The incidence and impact of malnutrition in older people is underestimated. The best option for treating malnutrition is to enhance normal eating and drinking. A “Food First” approach encourages eating frequent, small, high energy and protein meals and snacks. Nutritional supplements for weight gain are generally not required unless body weight is unable to be maintained with a normal balanced diet, or if food cannot be eaten safely.

Key concepts

The incidence and impact of malnutrition in elderly people is underestimated

Routine screening for malnutrition should be implemented for people in at risk groups

“Food First” – eating small but frequent, high energy, high protein snacks and meals – is
the first treatment option for elderly people who are malnourished

Use of oral nutritional supplements (ready-made sip feeds or powders which are mixed with water or milk) is generally
not recommended until a Food First approach has been trialled

Nutrition support is recommended for malnourished people who are unable to maintain body weight by food intake alone

Oral nutritional supplements are a top-up to food intake rather than a replacement – they should be given between
meals, not at meal times

Changes to the funding of oral nutritional supplements

PHARMAC has recently made a number of changes to the access and funding of oral nutritional supplements, including
powders for reconstitution and ready-made liquids. These changes include:

Reducing the funding of ready-made liquids to the level of powder alternatives

Widening access to those who can initiate funding (vocationally registered general practitioners can now make initial
Special Authority applications)

Restricting funding to people who are malnourished or who have one of a number of listed specific indications which
places them at high risk of malnourishment

Emphasising “Food First” and regular review of patients

Background to the recent funding changes

In New Zealand, use of ready-made liquid supplements has been increasing steadily. Expenditure on standard adult oral
and enteral products was $6.7 million in 2008/09 with annual growth of 13%. Of this, $5.7 million was for ready-made
liquids, e.g. Ensure Plus and Fortisip (see graph Allergy to cows’ milk protein and the appropriate use
of infant formula).

In the United Kingdom there has been concern regarding the treatment approach to malnutrition in elderly people. This
has resulted in the formulation of treatment guidelines emphasising the provision of nutritional supplementation to only
those who are malnourished or at a high risk of malnourishment, an emphasis on the use of first line dietary advice (Food
First), and regular patient reviews

Defining malnutrition

Malnutrition is both a “cause and a consequence of ill-health”.1 The term malnutrition can apply
to various states – under-nutrition, over-nutrition or deficiencies of specific nutrients. This article will concentrate
on under-nutrition, and the term malnutrition when used will refer to this state. More specifically, malnutrition in this
context refers to a deficiency in protein and energy, with or without micronutrient deficiencies. Such deficiencies are
associated with a decline in body functioning and clinical outcome. The consequences of malnutrition are physiological,
biochemical and psychological. They include reduced immunity, delayed wound healing and decreased muscle strength, which
in turn have detrimental effects on recovery and rehabilitation. The psycho-social impact of malnutrition is also significant
with changes in mood, attitude, self esteem and reduced socialisation.1,2,3

Prevalence of under-nutrition

Estimates of prevalence of under-nutrition in elderly people:

Prevalence

Type of population

Over 10%

Non-institutionalised elderly people1

10 – 50%

Hospitalised for acute illness4

10 – 70%

Long care units or nursing homes1,5

Causes of malnutrition

The “anorexia of ageing”6,7

Appetite and food intake often decline with ageing. Older people tend to be consistently less hungry than younger people,
eat smaller meals, have fewer snacks between meals and also eat more slowly.8 Between age 20 and 80 years,
there is on average, a decrease in energy intake of approximately 30%. When this decline in energy intake is more than
the decrease in energy use that is also normal with ageing, then there is loss of weight.8

Most people lose weight as they age, but the amount lost is variable and those that are already lean, also lose weight.
The problem with this weight loss is that it is not only unwanted adipose tissue that is lost but lean skeletal muscle.9 The
loss of lean tissue is associated with reductions in muscle function, bone mass and cognitive function, anaemia, dysfunction
of the immune system, slow wound healing and recovery from surgery, and consequentially an increase in both morbidity
and mortality.8,9 Although lean muscle can be regained in younger people this is often not the case for elderly
people. This means that being underweight becomes more of a health problem in older age, than being overweight.

Increasing age has several effects on gastrointestinal function. Secretion of gastric acid, intrinsic factor and pepsin
is decreased, which then reduces the absorption of vitamin B6, B12, folate, iron and calcium. Other gastrointestinal problems
such as gastritis and gastrointestinal cancers can reduce nutritional status.10

A hypermetabolic state where there is increased resting energy use can be caused by acute respiratory or urinary infections,
sepsis, cirrhosis of the liver, hyperthyroidism and the hyperactive state found in some people with dementia or Parkinson’s
disease.10 Chronic obstructive pulmonary disease (COPD) can cause anorexia and physical problems related to
shortness of breath (see here).

In addition to the “anorexia of ageing”, there are physical, social, cultural, environmental and financial
reasons for an inadequate diet.1,8

Impaired intake

Poor appetite: illness, pain or nausea when eating, depression or anxiety, social isolation or living
alone, bereavement or other significant life event, food aversion, resistance to change, lack of understanding linking
diet and health, beliefs regarding dietary restrictions, alcoholism, reduced sense of taste or smell.

Inability to eat: confusion, diminished conscious­ness, dementia, weakness or arthritis in the arms
or hands, dysphagia, vomiting, COPD, painful mouth conditions, poor oral hygiene or dentition, restrictions imposed by
surgery or investigations, lack of help while eating for those in hospitals and rest homes.

Surgery: The metabolic changes caused by surgery, the increased demands required for successful healing,
sepsis and the stress of the surgical procedure itself, all increase energy needs.11 To supply this energy,
protein stored as muscle is broken down and amino acids released. A septic state will increase this muscle breakdown further.
Nutritional requirements must meet these increased needs. Furthermore, patients may already be malnourished due to the
illness that led to their surgery.

Once discharged, there will be ongoing higher nutritional needs during the recovery phase, although muscle lost may
never be regained. Oral nutritional supplements may be useful during the recovery period, particularly if there are modifications
to dietary intake as a consequence of the surgery, e.g. texture modification, low residue diet.

Cancer: People with cancer are often malnourished. Physical and metabolic changes can be compounded
by social and psychological problems.12 Treatment adverse effects such as taste changes, nausea or swallowing
difficulties also result in a reduced food and nutrient intake. Cancer may result in cachexic syndrome which is a state
of complex metabolic changes associated with anorexia, progressive weight loss and depletion of reserves of adipose tissue
and skeletal muscle. Weight loss adversely affects treatment tolerance and survival outcomes.

Nutritional advice tailored on an individual basis should be given at an early stage to help prevent nutritional deficiencies.13 Loss
of appetite, pain, nausea and vomiting all contribute to poor oral intake. Prednisone may be used to stimulate appetite,
but its effect tends to be short lived.14

Oral nutritional supplements can be beneficial when a normal balanced diet cannot be tolerated. These supplements help
prevent malnutrition but eventually cannot halt the cachexic state associated with many end-stage cancers.

Chronic Kidney Disease (CKD)15 Nutritional requirements for people with CKD vary widely.
In general, they require a diet that promotes adequate nutrition, minimises biochemical abnormalities and delays the progression
of CKD. In later stages of CKD appetite is often poor and there is a high risk of malnutrition.

Guidance should be given to ensure the protein intake meets the recommended daily intake for the patients’ age
and gender and adequate energy is consumed. Micronutrients such as potassium and phosphorous should only be restricted
if blood levels are elevated. The aim of treatment is to prevent malnutrition.

People requiring haemodialysis have some differing needs – they require 1.2 – 1.4 g/kg/day of protein due
to losses in the dialysate. Some people may require adjustment of micronutrient intake, but this is dependent on the individual’s
clinical and biochemical profile.

There are specialised renal nutritional supplements available on the Pharmaceutical Schedule. These are indicated for
patients requiring volume and potassium restrictions. For many patients, standard oral nutritional supplements will be
suitable in the first instance.

How do we detect under-nutrition?

The onset of nutritional problems is often gradual and therefore hard to detect. However, features found in the history
and examination may help identify those at risk. People can present with a variety of problems that may be vague or non-specific.
Patients may report reduced appetite and energy and have altered taste sensation and changes to their normal bowel habit.1 Clinical
features that may suggest under nourishment include low body weight, fragile skin, wasted muscles, recurrent infections
and impaired wound healing.1

A malnourished state is defined as any of the following:1

BMI < 18.5 kg/m2

Unintentional weight loss > 10% within the last three to six months

BMI < 20 kg/m2 and unintentional weight loss > 5% within the last three to six months

% weight loss =

original weight - current weight

x 100

current weight

BMI =

weight(kg)

height(m)2

Screening for malnutrition risk

In many cases clinical judgment is sufficient to diagnose under-nutrition. However, not everyone who is malnourished
is thin. Objective classification of a patient’s risk of malnutrition assists clinical decision making. A validated
and reliable nutrition screening tool is the first step in identifying at risk patients.

Screening should also be considered at other opportunities, e.g. health checks, influenza injections, and repeated regularly
for people in recognised risk groups.

Nutrition screening is defined as a quick and simple evaluation that detects the risk of malnutrition and guides implementation
of a clear action plan.1,16 The NICE guidelines recommend the Malnutrition Universal Screening Tool (MUST)
which aggregates scores for BMI, unintentional weight loss (over three to six months) and an acute illness or lack of
adequate food for more than five days.1

Malnutrition Universal Screening Tool (MUST)

Malnutrition Universal Screening Tool (MUST)

MUST was originally designed for residential and community settings, however, it has now been validated in the acute
setting, allowing screening to occur across the continuum of care. It takes on average three to five minutes to complete
and includes clear treatment plans depending on the level of risk identified (Figure 1).

Further information and instructions on the use of the MUST toolkit
are available from: www.bapen.org.uk

The full MUST toolkit includes tables that allow scoring of BMI and % weight loss without having to calculate the individual
indices. These can be printed for clinical use. There is also a MUST calculator available to further speed up the screening
process.

Treat underlying condition and provide help and advice on food choices, eating and drinking when necessary.

Record malnutrition risk category.

Record need for special diets and follow local policy.

Record presence of obesity. For those with underlying conditions, these are generally controlled before the treatment
of obesity.

Re-assess subjects identified at risk as they move through care settings
See The ‘MUST’ Explanatory Booklet for further details and The ‘MUST’ Report for supporting evidence.

Laboratory testing

Laboratory testing is not useful for diagnosing malnutrition, however, some tests may be required to detect specific
deficiencies such as iron, folate and vitamin B12.1,10 Albumin has been suggested in the past as a marker of
nutritional status but it is now regarded as unhelpful due to the fact that it can be altered by clinical conditions such
as dehydration and inflammation.17

Re-feeding Syndrome

Re-feeding syndrome occurs when nutrition support is re-introduced too quickly after a period of significantly reduced
intake or starvation. The subsequent change from fat to carbohydrate metabolism causes alterations in electrolyte levels,
such as hypophosphataemia, hypokalaemia and hypomagnesaemia. Thiamine levels may also be reduced.18

NICE recommends that people who have eaten little or nothing for five or more days have nutrition support introduced
slowly, at a rate of 50% of requirements. Patients at high risk of re-feeding syndrome should be managed by a team who
has expert knowledge of nutritional requirements and care.1

Patients at high risk of re-feeding syndrome1

One or more of the following:

BMI less than 16 kg/m2

Unintentional weight loss greater than 15% within the last three to six months

Little or no nutritional intake for more than ten days

Low levels of potassium, phosphate or magnesium prior to feeding

Two or more of the following:

BMI less than 18.5 kg/m2

Unintentional weight loss greater than 10% within the last three to six months

Little or no nutritional intake for more than five days

A history of alcohol misuse or taking medicines including insulin, chemotherapy, antacids or diuretics

Nutrition support strategies

Nutrition support is not limited to providing supplements in the form of oral nutritional supplements (ready-made liquids
or powdered sip feeds) or enteral feeding. The first step should always be to maximise an individual’s
nutritional intake from regular food and drink, often termed “Food First”. The Food First approach includes
increasing the frequency of eating, maximising the nutrient and energy density of food and drink and fortifying food with
the addition of fats and sugars. Strategies to optimise adequate oral nutrition are summarised in Table 1.

Table 1: Ways to optimise oral nutrition in elderly people10,19

Problem

Solution

Loss of appetite

Check medications: alter where possible to minimise adverse effects

Encourage “little and often” – three small meals with regular in-between snacks of energy rich,
high protein foods (see Practical food suggestions). Encourage people to eat every two to
three hours.

Maximise times of better appetite, e.g. if hungry in the morning suggest a cooked breakfast – eggs, baked
beans, cheese on toast

Serve meals and snacks that are appealing in size and appearance – large meals can be off putting, use small
plates and maximise the “eye appeal” of the food

Food has to be eaten to be of benefit – encourage the patient to select favourite foods that can be eaten
at any time, e.g. cereal for supper, soup for breakfast

Drinks can lessen appetite – suggest that drinks are taken after meals rather than before and during a meal

Find ways to stimulate the appetite – a short walk before meals can be helpful

Consider meal settings – make meal times enjoyable and avoid interruptions or rushing during meals

Chewing problems

Encourage adequate dental and mouth care

Try soft foods that require little chewing – tender cuts of meat cooked in gravies are often more easily
managed

In some situations a Food First approach can be sufficient to correct malnutrition outcomes (see “Practical food
suggestions”).5 For patients who are at very high risk of malnutrition or for whom first-line dietary
measures are not sufficient, oral nutritional supplements should be considered in combination with the Food First approach.1,16

Practical food suggestions for people who are malnourished

Healthy eating guidelines promote low fat and low sugar food choices. Patients who are malnourished or losing weight
unintentionally, however, must rely on fat and sugar as concentrated sources of calories. The benefit of energy dense
foods in these circumstances should be explained to patients and carers to assist compliance. Ideally fats should be
heart healthy (oils, margarines, seeds and nuts) but with the priority being to ensure an energy dense intake. Calories
from butter, cream, full fat milk and cheese can be utilised.

Scones, pikelets, english muffins, crumpets or toast with liberal spreads

Dried fruit and nuts (with a little chocolate if enjoyed)

Protein filled sandwiches

Sweet muffins, cakes and pastries

Other beneficial products available in supermarkets include Complan, Vitaplan and Up & Go. These products are not nutritionally
complete and should not be used as a sole source of nutrition. They can, however, be used as part of the Food First approach
as the overall emphasis for these patients should be eating foods high in calories and protein.

Evidence that oral nutritional supplements improve health outcomes is limited. A systematic (Cochrane) review of 62
trials, updated in 2009, concluded that there was evidence of small consistent weight gain following the use of oral nutritional
supplements and that for undernourished patients mortality is possibly reduced.3 In addition, there was greater
evidence of a reduction in complications compared to previous reviews but the reviewers noted that the data was limited
and of poor quality. A further review of dietary advice for illness related malnutrition in adults could not clearly define
whether dietary advice or supplements provided better outcomes.20 The reviewers concluded that nutritional
intervention (oral nutritional supplement plus other dietary measures) was more effective than no intervention on enhancing
short term weight gain but whether survival or morbidity are improved remains uncertain. All reviews agree that oral nutritional
supplements are useful means of increasing protein, energy and micronutrient intake when used appropriately and as part
of a combination of nutrition support strategies.1,3,16

The success of oral nutritional supplements can be limited by a lack of compliance often due to low palatability, adverse
effects, e.g. nausea and diarrhoea, and by cost.16 Some studies have shown that there can be a decrease in
the consumption of normal foods when oral nutritional supplements are given,16,21 whereas other studies found
no effect on appetite.22 Wastage of up to 35% of these products is also reported.23

Best results are seen when people are offered a variety of different flavours and consistencies and also when the temperature
at which the products are consumed is varied.16Oral nutritional supplements should be given between
meals, not at meal times and there is some evidence of improved adherence if administered in small regular doses
similar to a medicine.5 They are not usually intended as a food replacement but as a supplement.

As part of clinical monitoring, prescribers should check that patients are using oral nutritional supplements appropriately, as
a top up to their food intake rather than a replacement. Ensure patients are clear about the role of oral nutritional
supplements in their overall nutritional care.

After trying Food First, oral nutritional supplements should be considered where a patient has been identified at medium
to high risk of malnutrition, ideally in combination with Food First. The prescription should be based on the gap between
the patient’s estimated requirements and how much they are managing orally. The need for continuation of an oral
nutritional supplement should be monitored regularly and adjusted as malnutrition risk reduces.1,5

Considering prescription of oral nutritional supplements

Vocationally registered medical practitioners are now able to make initial applications for Special Food Special Authorities.
It is intended that dietitians will also be able to make applications in the near future. The eligibility criteria for
Special Authorities give clear guidance on who should be considered for oral nutritional supplements. The reduced time
span of initial applications encourages regular monitoring and evaluation of continuation of oral nutritional supplements.

The evaluation pathway is summarised in Figure 2.

Figure 2: The evaluation pathway summary

* Monitoring and evaluation considerations may include:

Is the patient using the supplement? Is there any wastage?

Is the supplement an addition to food or is it replacing food?

Changes in weight – is this being recorded?

Could the patient be encouraged to adopt a diet that meets their nutritional needs, through reiteration of the Food
First approach?

Is there a plan in place to gradually replace use of the supplement with a regular diet?

Does the patient understand the supplementary role of oral nutritional supplements? Do they require additional ideas
or tips on how best to maximise compliance? E.g. recipes, timing in relation to other food and drinks.

Suitable oral nutritional supplements for patients who have been identified at risk of malnutrition

Points for consideration:

Encourage the patient to use Food First principles

The powdered supplements are fully funded whereas the ready-made liquids are not. Full funding is available via “endorsement” for
tube fed patients when using the ready-made liquids as a bolus tube feed.

Is the patient lactose intolerant? Ensure Powder with water, and the ready-made liquids (Fortisip and Ensure Plus)
are lactose free.

Is the patient volume challenged? i.e. do they struggle to drink fluids at any volume? If so they should use a product
which provides 1.5 kcal/mL.

Measured volumes for mixing do not have to be exact, e.g 200 mL can be used instead of 196 mL. The key is to have
the recommended amount of powder per day.

Whilst there is a part charge for the ready-made liquid supplements, some patients may be willing to pay this especially
if they prefer the taste and flavour varieties of the ready-made drinks or find it difficult to physically mix the powdered
drinks or find the ready-made drinks convenient to carry when away from home.

Is constipation an issue? Fortisip multifibre contains a mix of dietary fibres (4.6 g/200 mL) while the powdered drinks
have a lower fibre content (Table 2).

Table 2: Nutritional composition of the ready-made and powdered drinks when mixed with
water and milk

Product

Mix

Vol(mL)

Kcal per serve

Kcal per mL

Protein per serve

Fibre per serve

Lactose

Subsidy

Powder drinks when mixed with water

Ensure powder (can)

6 scoops (53g)+ 195ml of water

230mL

230

1.0

8.5

2g

No

Full

Sustagen hospital formula (can)

3 scoops (60g) + 200ml of water

240ml

228

1.0

13.8

0g

Yes

Full

Ensure powder (can)

9 scoops (80g) + 180ml water

230ml

345

1.5

15

3g

No

Full

Powder drinks when mixed with 200ml of standard (blue top) milk

Ensure powder (can)

6 scoops (53g)

230ml

354

1.5

15

2g

Yes

Full

Sustagen hospital formula (can)

3 scoops (57g)

240ml

352

1.5

20.3

0g

Yes

Full

Ready-made drinks

Ensure plus (cans)

n/a

237ml

355

1.5

13

0g

No

Part

Ensure plus (tetrapak)

n/a

200ml

300

1.5

12.5

0g

No

Part

Fortisip (bottle)

n/a

200ml

300

1.5

12

0g

No

Part

Fortisip multifibre (bottle)

n/a

200ml

300

1.5

12

4.6g

No

Part

Two cal HN (can)

n/a

237ml

474

2.0

19.9

2.0g

No

Part

Note: these instructions may vary from the mixing instructions on some of these products

Changing from ready-made liquids to a powder

When considering whether it is suitable for a patient to change from a ready-made liquid sip feed to a powdered sip
feed the main considerations are; the purpose for which the patient needs the sip feed, the nutrient density of the sip
feed, hidden costs and convenience.

Powdered sip feeds are not suitable for tube feeding. The ready-made sip feeds are fully subsidised where prescriptions
are endorsed with “Bolus fed through a feeding tube”. It is possible to also use fully subsidised tube feeding
formula. Refer the patient to a dietitian for full review and recommendations.

Nutritional content

The ready-made liquid sip feeds, e.g. Ensure Plus and Fortisip, are 1.5 kcal/mL with 12 – 13g of protein per serve.
In comparison, the powdered sip feeds (Ensure Powder and Sustagen Hospital Formula) when mixed with water according to
the instructions provide 1.0 kcal/mL with 8.5 g and 13.8 g protein/serve respectively. By making a direct switch to standard
dilution powdered drinks the nutrient density is reduced. This can be overcome if the powder is mixed with milk, the patient
drinks a larger volume, or the powder is concentrated (refer to the mixing instructions in Table 2).

Tips for patients using powdered products

Use the scoop provided so that the correct amount of powder is used

Sustagen Hospital Formula and Ensure powder can be mixed with either water or milk
(preferably whole or full fat milk)

Mix using a spoon, fork, shaker, whisk or blender until the powder has dissolved – it may be easier to mix
if the water/milk is added to the powder, rather than vice versa

Once mixed, it can be drunk straight away. Any leftover mixture can be covered and placed in the fridge for up to 24
hours. After 24 hours it should be thrown away.

Enteral feeding

In its broadest sense enteral nutrition refers to any feeding method that uses the gastrointestinal tract. More commonly,
however, the term enteral feeding refers to methods of providing food via a tube directly into the gastrointestinal system.

The tube can be inserted through the nose to the stomach (nasogastric) or to the small intestine (nasoduodenal or nasojejeunal).
Alternatively a feeding tube can be placed via the abdominal wall directly into the stomach (gastrostomy). Percutaenous
Endoscopic Gastrostomy (or PEGs) refers to gastrostomy tubes that are placed using endoscopy.16

Enteral (tube) feeding should be considered for people who cannot eat and drink safely, such as with dysphagia following
a stroke. It can also be used when people cannot maintain an adequate diet from normal food and fluids or from oral supplements.

If tube feeding is likely to be required for more than four weeks, then insertion of a PEG/gastrostomy tube may be required.16 The
main benefit of gastrostomy tube over a nasogastric tube is patient comfort. It is also less likely to be displaced and
can be hidden under clothes.1 However, a PEG is invasive and the risk of aspiration remains with both nasogastric
and PEG feeding.24

NICE recommends that tube feeding in the community is delivered by health professionals trained in nutrition support
using a coordinated multidisciplinary team approach.1 The team should include dietitians, district nursing,
GPs and community pharmacists. Additional allied health staff should be involved as needed, e.g. speech and language therapists,
occupational therapists. Monitoring of tolerance and oral intake by the team will provide guidance of when enteral feeding
should be stopped.1

The use of tube feeding in people who are chronically unwell is controversial, especially when used for people with
dementia. The debate focuses on the selection of which people will benefit from this form of nutritional supplementation.25 Both
oral supplements and tube feeding can improve the nutritional state of people with dementia. European Society Parenteral
and Enteral Nutrition (ESPEN) guidelines recommend that its use be considered in early and moderate dementia, however,
not in terminal dementia.

The decision regarding the use of tube feeding must always be made on an individual basis with input from relatives,
caregivers, GP, therapists and if required, legal representation.16

Considerations for the use of long-term tube feeding may include:16

Does the patient suffer from a condition likely to benefit from enteral feeding?

Will nutritional support improve outcome and/or accelerate recovery?

Does the patient suffer from an incurable disease, but one in which quality of life and wellbeing can be maintained
or improved by enteral nutrition?

Does the anticipated benefit outweigh the potential risks?

Does the use of enteral nutrition agree with the expressed or presumed will of the patient or in the case of incompetent
patients of his/her legal representative?

Are there sufficient resources available to manage enteral nutrition properly? If long-term enteral nutrition implies
a different living situation, e.g. home vs institution, will the change benefit the patient overall?

Caution! Medicines and enteral feeds should not be mixed. Temporarily stop the tube feed flush with
water, administer individual medicines, flushing the tube before and after each dose. Resume feeding.

Parenteral nutrition

Parenteral nutrition is a method of providing nutrition directly into the venous system, usually via a central line
and so avoiding the digestive system. It is referred to as total parenteral nutrition and in general is used in a hospital
setting. Its use in the community is mainly reserved for people with severe Crohn’s disease, those with vascular
damage to the bowel and some people with cancer. Home parenteral nutrition is expensive and requires careful patient selection
and training and should be managed by a healthcare professionals trained in parenteral nutrition.

Acknowledgement

Thank you to Professor Tim Wilkinson, Associate Dean, Christchurch School of Medicine and Health Sciences,
University of Otago and Dr Sandy McLeod, Medical Director, Nurse Maude Hospice, Christchurch, for expert
guidance in developing the original article which appeared in BPJ 15 (Aug,
2008).

References

National Institute for Health and Clinical Excellence (NICE). Nutritional support in adults. NICE, 2006.. Available
from: www.nice.org.uk/Guidance/CG32 (Accessed Apr,
2011).

European Nutrition for Health Alliance (ENHA). Malnutrition among older people in the community: policy recommendations
for change. ENHA,2006.. Available from: www.bapen.org.uk/pdfs (Accessed
Apr, 2011).